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Page 14 • Pelican News October, November, December 2020 CBD Oil and Chronic Pain Susan E. Collins, RN, BSN, MBA Reprinted with permission from ANA-Maine Journal May 2020 issue Thesis statement: Cannabidiol (CBD) oil is an effective means to treat chronic pain in adults. Purpose statement: Chronic pain is a growing issue in the United States and worldwide. This paper will examine current studies completed within the last five years on the use of CBD oil, or a combination of oils to include CBD oil, for pain management (Smith 2019) of chronic pain. A brief description on the epidemic of chronic pain in relation to several conditions, such as cancer, neuropathic pain (Smith 2019), and musculoskeletal pain will be given, noting the current traditional methods of treatment. Current research will be reviewed and discussed in the use of CBD oil, or a combination treatment including CBD oil, noting findings, current results, and potentials for future studies. Abstract Chronic pain is a growing issue in the United States and worldwide. This paper examined current studies completed within the last five years on the use of Cannabidiol oil, or a combination of oils to include Cannabidiol oil, for pain management (Smith 2019) of chronic pain. A brief description on the epidemic of chronic pain in relation to several conditions, such as cancer, neuropathic pain (Smith 2019), and musculoskeletal pain will be given, noting the current traditional methods of treatment. Current research will be reviewed and discussed in the use of Cannabidiol oil, or a combination treatment including Cannabidiol oil, noting findings, current results, and potentials for future studies. Several current studies completed within the last five years focused on Cannabidiol oil as a standalone or adjunct treatment for chronic pain in adults. Combinations of Cannabidiol oil and delta-9-tetrahydrocannabinol (THC) were used in most studies, however, dosing was found to be inconsistent, patient samples generally small, and repeat studies non-existent. With continued legislation changes and lack of Food and Drug Administration involvement in Cannabidiol oil products, Cannabidiol oil remains a viable option for use in the spotlight of the general public, but with little backing from the scientific community. Keywords: cannabinoids, cannabidiol, cannabis, CBD, delta-9-tetrahydrocannabinol, THC, pain, chronic pain, pain management Introduction CBD oil advertisements are cropping up in window fronts, convenience stores, video stores, the local gas station, and everywhere that people routinely shop. Amazing results are touted, by manufacturers, from “natural” CBD products and oils. CBD oil is being marketed to those with chronic pain, multiple sclerosis, seizures or epilepsy, anxiety, mental disorders, and a multitude of medical conditions, often those that are chronic. It offers Recruiting all RN’s New Base Pay Rates Eastern LA Mental Health System Call (225) 634-4303 for more info The largest publicly founded Mental Health System in Louisiana a ray of hope to those who seek a more “natural” remedy and to those who are tired and feel they have few options left. CBD oil and THC are derived from the same plant. THC is the element that causes a high, or euphoric feeling, while CBD oil typically is considered safe and non-intoxicating. Due to the individuality of plants, it is difficult for manufacturers to standardize the amounts of THC or CBD in over the counter or prescription products, since no two plants are completely identical. This has caused a significant issue with testing of these products in medical studies, as has the issue of legalization of the products in many states or countries. CBD oil is available in a variety of forms, including oils, tinctures, edibles, gummies, rubs, lotions, capsules, tablets, and even aerosolized. Dosing is not standardized, and there is no government recommended daily allowance available, so the consumer must either research or believe what is printed on the products or advertisements. This study hopes to shed light on some of the current research being done on the use of CBD oil, in its various forms and combinations, in an effort to educate the consumer and give support to further study in the use of CBD oil for chronic pain. Several products that combine CBD and THC are available in various countries by prescription. These include Bedrocan (THC/CBD), Tilray (THC/CBD), Sativex (THC/ CBD), Epidiolex (CBD), Dronabinol (THC), Nabilone (THC), as well as several nonmedicinal formulations. The majority are derived from the natural plant, but there are synthetic variations available. Current research studies offer a glimpse into the use of CBD oil as a combination therapy with THC, and a few support CBD oil as a singular, standalone therapy. However, there are few follow up studies available, a lack of legalization of THC or CBD products in many countries, and a lack of standardization in dosing that has caused a delay in studies or prevented them altogether. An Italian study conducted in 2017 (Fanelli et al.) looked at the treatment of chronic pain in 614 adults, who suffered from a variety of conditions. They used a combination of CBD and THC, in oral and vaporized forms, in patients who were running out of options and had tried numerous therapies and treatments, but with no avail. The inclusion of the CBD oil and THC therapy seemed to serve as an “effective and safe” means of treating chronic pain in this sample. A separate study by Mondello et al. (2018) looked at an 11-patient sample, suffering from neuropathic pain at a singular Italian clinic, after being diagnosed with “failed back surgery syndrome.” The small sample group had used spinal cord stimulation with little success. The inclusion of a combination of CBD and THC greatly improved their pain relief when used as an adjunct to spinal cord stimulation. A very small study with promising results was completed by Kiefer, D. (2017). Its focus was on the use of “topical cannabis for wound pain.” The Leading the way in Mental Health Care! sample size was three and the treatment was an infused sunflower oil and cannabis combination applied topically to wounds. Overall results revealed that the treatment produced impressive results when looking at a decrease in overall pain scores and a decrease in opioid use. This retrospective study seeks to support the thesis statement that cannabidiol (CBD) oil is an effective means to treat chronic pain in adults. Results Should CBD Be Part of My Patients Treatment was an original research study from Dick Benson (2019). The objective of this study was to educate the provider or practitioner on the endocannabinoid system, its importance to the human body, and its functioning and maintenance of homeostasis, while discussing various dosages that can be effective for a moderate list of medical conditions based upon research review. He wanted to emphasize the benefits of CBD oil and promote the use of it as a legitimate and legally recognized treatment in the medical community. His research findings validated the importance of the endocannabinoid system to the health of the human body and the use of CBD as an effective treatment or adjunct treatment for pain, anxiety, digestive issues, mood stabilization, and other common patient complaints. Mondello et al. (2018) completed research on the use of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) of patients with “failed back surgery syndrome (FBSS)” and the treatment of refractory pain. The authors treated the participants with an oral combination of THC and CBD as an effective alternative treatment for chronic refractory pain in patients with FBSS when used as an adjunct to spinal cord stimulation (SCS). The researchers performed a retrospective study on patients who were treated with a combination of THC and CBD while using SCS for twelve consecutive months, in an effort to diminish/ manage pain, improve participants quality of life, and functional ability following the development of a chronic refractory pain condition post back surgery. Findings revealed a significant reduction in pain when compared to the participants initial rating of their pain and functioning with only SCS. This suggested enhanced pain relief, improved function, and an overall improved quality of life for the participant, thus provided significant support for the use of THC and CBD as an adjunct for pain control. Effective cannabinoid use for the treatment of chronic pain was explored by Fanelli et al. (2017) through a retrospective study of 614 Italian patients. The focus of the study was to evaluate the use of 9-tetrahydrocannabinol (THC) and CBD use for the treatment of several chronic pain conditions, after the Italian government approved the use of cannabis for legalized use for treatment. A specific pain modality of oral ingestion was the focus, as it was noted that this was the primary treatment prescribed by practitioners. Results revealed that THC and CBD were effective in treating chronic pain, but noted that many patients still continued using their previously prescribed treatment. This would suggest that THC and CBD would be a successful adjunct therapy versus a standalone treatment. In 2016, a Canadian study was completed and published in the Journal of Pain Research by Ko, G.D., Bober, S. L., Mindra, S., and Moreau, J. M., that reviewed the barriers and concerns of THC and CBD use in the Canadian healthcare system for the treatment of chronic pain. A systematic review of available research, discussed cannabis, concerns for its use, legalization, prescribing methods, social concerns, availability of various preparations of cannabis, and medical cannabis regulations effecting or influencing Canadian citizens utilizing THC and CBD preparations from a prescribing practitioner. The authors came to the conclusion that with education and evidenced based treatment approaches, practitioners can safely and effectively utilize cannabis, THC, and CBD for the treatment of pain and reduce the use of narcotics. In November of 2018, “unlicensed cannabis based products” were able to be prescribed in the United Kingdom, as cited in a systematic review completed by Freeman, T. P., Hindocha, C., Green, S. F., & Bloomfield, M. A. P. Six available products authorized in the United Kingdom, were compared based upon prescribing standards, licensed indications, and authorized prescribers.
October, November, December 2020 Pelican News • Page 15 Authors wanted to provide education and discuss the various implications associated with the six drugs with emphasis on use in the United Kingdom, but noted considerations and some comparisons with other developed countries. Much discussion was provided on legal considerations and variation in products, revealing minimal standardization requirements for those products sold over the counter. Results noted that cannabis, THC, and CBD are being used for the treatment of chronic pain, with varying degrees of success as cited in 14 studies with a total of 2978 participants involving a singular prescribed commercial product containing a combination of THC and CBD (Sativex). An interesting, yet very limited research study, completed by David Keifer in 2017, demonstrated the usefulness of a topical cannabis (a combination of THC and CBD) for the treatment of pain in three patients with gangrene. Traditional treatments, opioids, and combinations therapies, had demonstrated little benefit to the patients, so Keifer opted for a non-conventional approach experimenting with new products. Results were found to be significant in two of the three participants, with other benefits noted to be reduced opioid use in two patients. This study was small, but could possibly lead the way for further controlled studies. The majority of studies reviewed, strongly suggested and encouraged the completion of more randomized clinical trials to be completed distinguishing the effects of THC versus CBD versus other active components of cannabis to demonstrate the best combination for treatment modalities. Several authors noted that due to legal considerations and regulations in many countries, randomized trials and research were difficult to complete. It was felt that without further study, no conclusive dosage, preparation, combination therapy, or evidence could be finalized that best supported the individual patient or treatment of chronic pain. Discussion There is evidence to support that CBD oil is an effective treatment for chronic pain in adults, however not enough was found to support it as a standalone treatment. Most research has been on CBD oil combined with another oil, therapy, or substance, or used in combination with a different treatment regimen. This leads to the evidence more strongly supporting CBD oil as an adjunct therapy for chronic pain in adults. CBD oil is available in various forms, including lotions, creams, oils, food products, vaporized oils, and oral pharmaceutical variations. There is currently no standardized dosage or one size fits all recommended amount of CBD oil to use topically, orally, or vaporized. CBD oil is extracted from the hemp plant (Cannabis sativa L). You will not find two identical plants, thus the CBD oil extracted can have various amounts of THC present and other constituents. A limiting factor is if too much THC is present in extracted CBD oil, then it cannot be sold legally in many states or countries, for it would be considered marijuana. This would limit who could or would study it. Another consideration that still requires further study is the influence of individual human factors and variations on plant factors that can greatly influence or deter the potential benefits of CBD oil. Groups of individuals that participated in the current research were chosen based upon a single disease or condition predominately. Considerations for human factors such as weight, genetics, metabolism, plant factors such as environment, climate, or processing factors such as inconsistent manufacturing practices or processes that go into creating a CBD product were not addressed, thus further limiting support. Due to CBD oil popularity and “newness,” charlatans and opportunistic salesmen are promoting CBD cure-alls with little or questionable research available for the average person. CBD is proudly advertised at the local drug store, video store, health food chain, and it continues to pop up all over the country. The promise of miraculous cures, and healing properties from CBD infused foods, body products, oils, and numerous other creations, pique the curiosity of the average consumer, and offer hope to the chronic pain sufferer. Yet the science does not support these products and research is still in its early stages predominately due to legal issues surrounding the THC portion of the Cannabis sativa L plant. According to GOVERNING, as of June 25, 2019, in the United States, the District of Columbia and 11 states have passed laws into place that legalize marijuana for recreational use. In the past ten years, the United States and many countries, have seen a trend and felt the push, by citizens and consumers, to legalize marijuana and make it available for use by the common man for self-medication and recreation. Prior to this, research on CBD oil was very difficult to complete because it came from the same “illegal” plant known as marijuana, thus was not readily available for study and did not have the funding sources needed to complete studies that would be respected and well received by the medical community. To sum things up, CBD oil is promising. It has been found to help relieve pain, and various other chronic symptoms in smaller studies for different types of chronic pain in adults. When combined with THC or used as a supportive therapy to an already established treatment, it has proven to be beneficial in helping to diminish pain and improve the functionality and quality of life in adults with chronic pain. It is worth consideration for further study to examine its benefits in larger adult studies, as a standalone treatment, as well as a combination treatment. Once this has been completed, hopefully a standardized dosing system or usage will be approved by the Food and Drug Administration for use to in adults to provide relief for chronic pain in its many forms. Hope for an improved quality of life with less pain is a possibility through the use of CBD oil for adults with chronic pain. Conclusions Alternative medicine is still a new and developing concept to westernized medicine practitioners, but it is making head way in being accepted as a possible treatment for chronic conditions, including adult pain syndromes. With the legalization of marijuana in several states in the United States, and several countries, the use of CBD oil, THC, and cannabis has been a focus in the medical community and public. CBD oil is considered generally safe as an alternative treatment therapy which has promoted its use. CBD oil is generally combined with THC or cannabis as an alternative treatment modality. Many participants in current studies would continue current treatments during the trialed CBD oil and THC or cannabis combined therapy. So, it is unclear if the CBD oil and THC or cannabis combined therapy worked well on its own or had a positive or complementary effect on the current westernized treatment already in progress. The use of a combination therapy of administered CBD oil and THC shows great promise as an effective therapy for chronic pain. However, further research needs to be completed to support the CBD oil/ THC combined therapy due to a low number of participants and lack of standardized oils, dosages, and methods of administration. The legal aspects still surrounding marijuana in many countries and states, also greatly limits research. CBD oil is indeed promising, but at this time, the thesis that Cannabidiol (CBD) oil is an effective means to treat chronic pain in adults is not supported as a standalone treatment. References: Smith, K. (2019). What is CBD Oil … and why are we talking about it so much? Environmental Nutrition, 42 (8), 7. Retrieved from: https://search.proquest.com/do cview/2254474489?accountid=158302 GOVERNING The States and Localities (June 25, 2019) State Marijuana Laws in 2019 Map Retrieved from: https://www.governing.com/gov-data/safety-justice/ state-marijuana-laws-map-medical-recreational.html Benson, D. (2019). Should CBD Be Part of My Patients’ Treatment? Alternative Therapies in Health and Medicine, 25 (1), 8-11. Retrieved from: https://search. proquest.com/docview/2261146571?accountid=158302 Mondello, E., Quattrone, E., Cardia, L., Bova, G., Mallamace, R., Barbagallo, A.A., Mondello, C., Mannuccvi, C., Di Pietro, M., Arcoraci, V., Calapai, G. (2018). Cannabinoids and spinal cord stimulation for the treatment of failed back surgery syndrome refractory pain. Journal of Pain Research, 11, 1761-1767. doi: 10.2147/JPR.S166617 Fanelli, G., Carolis, G. D., Leonardi, C., Longobardi, A., Sarli, E., Allegri, M., & Schatman, M. E. (2017). Cannabis and intractable chronic pain: An explorative retrospective analysis of Italian cohort of 614 patients. Journal of Pain Research, 10, 1217-1224. doi:http:// dx.doi.org/10.2147/JPR.S132814 Ko, G. D., Bober, S. L., Mindra, S., & Moreau, J. M. (2016). Medical cannabis - the Canadian perspective. Journal of Pain Research, 9, 735-744. doi:http://dx.doi. org/10.2147/JPR.S98182 Freeman, T. P., Hindocha, C., Green, S. F., & Bloomfield, M. A. P. (2019). Medicinal use of cannabis based products and cannabinoids. BMJ: British Medical Journal (Online), 365 doi:http://dx.doi.org/10.1136/bmj.l1141 Kiefer, D. (2017). Topical cannabis for wound pain: A case series. Integrative Medicine Alert, 20, (12) Retrieved from: https://search.proquest.com/docview/19781899 64?accountid=158302 Teitelbaum, J. (2019). A hemp oil, CBD, and marijuana primer: Powerful pain, insomnia, and anxiety-relieving tools! Alternative Therapies in Health and Medicine, 25, 21-23. Retrieved from https://search.proquest.com/do cview/2261140637?accountid=158302 Blake, A., Wan, B.A, Malek, L., DeAngelis, C., Diaz, P., Lao, N., Chow, E., O’Hearn, S. (2017). A selective review of medical cannabis in cancer pain management. Annals of palliative medicine, 6 (Suppl 2), S215-S222. doi:10.21037/apm.2017.08.05 Cicchi, R., Sturiale, A., Nesi, G., Kapsokalyvas, D., Alemanno, G., Tonelli, F., Pavone, F. (2013). Multiphoton morpho-functional imaging of healthy colon mucosa, adenomatous polyp and adenocarcinoma. Biomedical Optics Express 4 (7) 1204-1213. doi: 10.1364/ BOE.4.001204 Freeman, T. P., Hindocha, C., Green, S. F., & Bloomfield, M. A. P. (2019). Medicinal use of cannabis based products and cannabinoids. BMJ: British Medical Journal (Online), 365 doi:http://dx.doi.org/10.1136/bmj.l1141
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Louisiana - October 2020

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